Piezosurgery Assisted Periodontally Accelerated Osteogenic Orthodontics: A Review

Madhumita Choudhari^1*, Pavan Bajaj², Chitrika Subhadarsanee³ and Surekha Godbole³

^*Correspondence: Madhumita Choudhari, Sharad Pawar Dental College & Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), India, Email:

Author info »

Introduction

Alveolar osteogenic orthodontics or “Periodontally accelerated osteogenic orthodontics” (PAOO) is a novel systematic exploration of improvements in orthodontic therapy. Adult orthodontic therapy has gained popularity as a result of increased awareness of orthodontic treatment and increased aesthetic demand from patients and oral health is an integral element of overall health, and awareness is the foundation for planning it. The long treatment period, dentofacial aesthetics, and the type of appliances in use have become potential problems pertaining to adult orthodontic treatment. Furthermore, patients wish their braces removed quickly and the treatment time reduced. It has been noted that the prolonged orthodontic treatment, especially in adults can cause periodontal disease and bone loss, which consequently contributes to relapse. Loss of bone and tissue is a typical component of several disorders including trauma, periodontal disease, reconstructive surgery, ageing and osteoporosis. Fixed orthodontic therapy is linked to enamel decalcification which is a well-known orthodontic treatment concern, also leads to periodontal disease. According to a study, in less than 30% of patients, adequate mandibular alignment was maintained after ten years of standard therapy. In a study on mandibular incisor relapse, Rothe, et al. found that patients with thinner mandibular cortices following debonding have a higher chance of dental relapse [1-7].

The pursuit of an "optimum response" of alveolar bone to applied "ideal force" has moved both periodontal and orthodontic specializations into the field of surgical dentofacial orthopaedics [8]. Due to the time and expense demands of regenerative treatments, practitioners are becoming increasingly interested in learning variables that influence the clinical result following reconstructive surgery in order to deliver the best feasible care to patient [4]. We are not reliant on pre-existing alveolar volume with this approach, and teeth can be moved 2 to 3 times further in almost one-third to one-fourth the total time it takes for regular orthodontic therapy [5]. PAOO have been reported to obviate the need for some orthognathic surgery. Patients aged 11 to 78 have been treated with remarkable biologic impunity due to their minimal morbidity. It also provides practitioners with a step-by-step technique for reducing side effects such recurrence, root resorption, insufficient basal bone, and bacterial time/load factors including caries and infection [3].

Historical Review

The notion of "bony block movement", in which disruption is caused to the cortical bone's thick, dense layer which provides the most resistance to tooth movement, was first proposed by Henrich Kole, et al. [5,9,10]. This resulted in moveable bone blocks in which teeth were implanted, enabling easy tooth mobility. In the year 1980, Harold M. Frost identified a direct link between the severity of the bone's injury, as well as the speed with which it heals. He coined this term "regional acceleratory phenomenon" (RAP) [5,9–11]. After integrating corticotomy and their studies on RAP in the 1990s, “Wilckodontics" also known as Periodontally Accelerated Osteogenic Orthodontics (PAOO) was first established in 1995 by the Wilcko Brothers-Dr. Thomas Wilcko (Periodontist) and Dr. William Wilcko (Orthodontist) [12].

Biological rationale

Harold M. Frost suggested in osseous/soft tissue surgery, surgical ablation of the tissues resulted in dramatic remodeling near the injured site and a lot of activity was observed (RAP). The RAP is a regional regeneration/ remodeling process in which tissue regenerates quicker than normal in response to unpleasant stimuli. Bone repair is 10 to 50 times faster than normal bone turnover as a result of this phenomenon. The development process of woven bone starts in the periosteal area and works its way up to the medullary bone, where it reaches its maximum thickness provides mechanical stability of bone after injury. The cortical woven bone begins to remodel into lamellar bone, whereas the medullary woven bone resorbs [11,13,14]. A brief localised demineralization-remineralization process in the alveolar bone was observed by Wilcko et al. The collagenous soft tissue matrix of the bone which remains remineralized further after OTM. As a result of the remineralization process, the orthodontic treatment outcome becomes more stable. They hypothesized that RAP would appear as a result of the aforementioned mechanism. This in turn affects the alveolar bone during damage (corticotomy) and during active tooth movement [15].

Principle and treatment procedure

This interdisciplinary treatment entails a collaborative effort between an orthodontist, periodontist, maxillofacial surgeon, and general dentist [15]. OTM is aided by corticotomy-assisted or corticotomy-facilitated orthodontics, which uses controlled surgical damage to promote bone metabolism. It's a procedure that's halfway between orthognathic surgery and conventional methods of orthodontic treatments. The tissues of the alveolar bone, which are largely rich in calcium deposits, are released 20 to 55 days after the regional acceleratory phenomenon, culminating in the mineralization of new bone. In regions where there are cuts, which extended into the crevices of the marrow, this raised the bone reaction and the levels of inflammatory indicators in the body (both local and systemic). Prior to the surgical procedure, orthodontic brackets with wire are used for a week following the treatment. The procedure involves reflection of flap, decortication, bone grafting followed by orthodontic adjustments [15,16].

Piezosurgery has been reported as a precise and safe technique of ostectomy in oral and maxillofacial surgeries [17]. It is a relatively recent surgical method that is utilized in place of, or in addition to the established oral surgical procedures. The movement of the piezosurgical knife is relatively minimal compared to standard instruments, resulting in greater cutting precision and reduced discomfort for the patient [18]. When compared to standard instruments, the piezosurgery device requires less physical force to operate, making it more manageable and allowing for more intraoperative control. Many advantages of piezosurgery over traditional corticotomy devices have been observed, including precise cutting and safety, less force required for greater surgical control, almost bleeding free surgical site selective cutting and minimal operative invasion, the oxygen molecules generated during cutting have an antibacterial effect, and ultrasound vibration stimulates cell metabolism, resulting in faster bone growth and repair., no risk of emphysema, and decreased postoperative pain [19].

Piezosurgery assisted periodontally accelerated osteogenic orthodontics

Vercellotti, et al. pioneered the use of “piezosurgery” instead of burs to create a conductive environment involving OTM in conjunction with traditional flap elevation. The Monocortical tooth dislocation and ligament distraction (MTDLD) technique combines two distinct dental movements that work independently but concurrently on opposing root surfaces. To reduce cortical bone resistance, a piezosurgical micro saw is used to execute vertical and horizontal microsurgical corticotomies around each tooth root surface matching the direction of movement. When large biomechanical stresses are applied immediately, the root and cortical bone dislocate together. The dislocation force quickly distracts ligament fibers on the root surface in the opposite direction of movement. During the osteogenic phase that follows, normal orthodontic biomechanics are used to achieve the final tooth movement [20]. These procedures were reported to be quite effective, but were also quite invasive due to the significant flap elevations and involvement of osseous surgeries. They have the potential to cause both postoperative pain and complications [18].

As a minimally invasive approach to creating surgical injury to the bone without flap reflection, the corticision technique was used by Park et al. in the year 2006 shortly followed by Kim et al. three years later [21,22]. To get through the gingiva and cortical bone without raising a buccal or lingual flap, use of a reinforced scalpel and a mallet was done by the aforementioned authors. The surgical damage caused the RAP effect and as a result there was rapid movement of the teeth during orthodontic therapy. The inability to graft soft or hard tissues to cure inadequacies and fortify the periodontium, as well as the repetitive malting which resulted in dizziness in some patients post-surgery, were the downsides of this approach [18].

Dibart, et al. described "piezocision," a new less invasive method [18]. This approach combines limited micro incisions on the buccal side to allow for the use of the piezoelectric scalpel, as well as selective tunneling for hard or soft tissue grafting. One week after orthodontic appliances are placed, piezocision is performed. A small vertical incision is made buccally and interproximal in the connected gingiva or mucosa once complete anesthesia has been obtained. The soft tissues and periosteum must be sliced to allow the insertion of the piezoelectric knife; therefore a midlevel incision is created between the roots of the teeth involved. The action of piezocision on the bone is confined and selective. The tip of the Piezotome is put into the previously produced vertical interproximal incisions on the arches or in isolated segments, and corticotomy is performed [23] (Table 1).

Table 1: Advantages and reports of various studies

Novel advancements

The non-invasive process of laser-assisted flapless corticotomy can reduce treatment time and periodontal damage. After Erbium, Chromium doped Yttrium Scandium Gallium Garnet (Er-Cr: YSGG) laser irradiation, it stimulates the motion of teeth by lowering the cortical bone layer (which is more resorption-resistant than spongious bone) without surgical flap reflection [28].

The ability to move teeth more quickly, resulting in shorter treatment times, is unquestionably beneficial in reducing adolescent anxiety about the length of traditional orthodontic treatment. In most cases, the PAOO treatment can correct malocclusion in 3 to 10 months [29]. By combining changes in the structure of the surrounding bone to complement the repositioning of the teeth, this therapy expedites orthodontic treatment. The PAOO technique necessitates the use of various changed diagnostic and therapeutic parameters, which, if learned, transform it into a significant new treatment alternative for patients [30].

Conclusion

Piezosurgery assisted corticotomy facilitated orthodontic treatment is an effective treatment strategy for reducing treatment time and overcoming the limitations of traditional corticotomy instruments. When compared to piezosurgery, PAOO with surgical bur results in a significant reduction in treatment time and an increase in retraction rate. However, the results obtained are limited, so more clinical studies with a larger number of subjects and long-term follow-up should be encouraged.

References

1. Thind SK, Chatterjee A, Arshad F, et al. A clinical comparative evaluation of periodontally accelerated osteogenic orthodontics with piezo and surgical bur: An interdisciplinary approach. J Indian Soc Periodontol 2018; 22:328.

Indexed at, Google Scholar, Cross Ref

2. Khan S, Dhiman MF, Asif S. Accelerating tooth movement: What options we have. J Dent Health Oral Disor Ther 2016; 5:381–383.

Indexed at, Google Scholar, Cross Ref

3. Wilcko MT, Wilcko WM, Bissada NF. An evidence-based analysis of periodontally accelerated orthodontic and osteogenic techniques: A synthesis of scientific perspectives. Seminars Orthodontics 2008; 305–3116.

Indexed at, Google Scholar, Cross Ref

4. Verulkar A, Kamble R, Srivastav S, et al. Evaluation of the awareness of different orthodontic treatment appliances in patients undergoing orthodontic treatment of Maharashtra–A survey. J Datta Meghe Inst Med Sci Univ 2020; 15:347.

Google Scholar

5. Pathak TS, Kini V, Kanagotagi S, et al. Wilckodontics. J Contemp Dent 2013; 3:15–19.
6. Gilani R, Bajaj P, Mankar N, et al. Photo catalytic silver modified orthodontic brackets–an innovative method for prevention of white spot lesions. J Evol Med Dent Sci 2020; 9:2787–2791.

Indexed at, Google Scholar

7. Rothe LE, Bollen AM, Little RM, et al. Trabecular and cortical bone as risk factors for orthodontic relapse. Am J Orthod Dentofac Orthop 2006; 130:476–484.

Indexed at, Google Scholar, Cross Ref

8. Bhattacharya P, Bhattacharya H, Anjum A, et al. Assessment of corticotomy facilitated tooth movement and changes in alveolar bone thickness-A CT scan study. J Clin Diagn Res 2014; 8:ZC26.

Indexed at, Google Scholar, Cross Ref

9. Hoogeveen EJ, Jansma J, Ren Y. Surgically facilitated orthodontic treatment: A systematic review. Am J Orthod Dentofacial Orthop 2014; 145:51–64.

Indexed at, Google Scholar, Cross Ref

10. Hwei PC, Thomas JT. Role of periodontal therapy in rapid tooth movement. J Med Dent Sci 2014; 13:62–65.

Indexed at, Google Scholar

11. Frost HM. The biology of fracture healing. An overview for clinicians. Part I. Clin Orthop 1989; 248:283–293.

Google Scholar

12. Sirisha K, Srinivas M, Ravindranath D. Wilckodontics-a novel synergy in time to save time. J Clin Diagn Res 2014; 8:322.

Indexed at, Google Scholar, Cross Ref

13. Frost HM. The regional acceleratory phenomenon: A review. Henry Ford Hosp Med J 1983; 31:3–9.

Indexed at, Google Scholar

14. Schilling T, Müller M, Minne HW, et al. Influence of inflammation-mediated osteopenia on the regional acceleratory phenomenon and the systemic acceleratory phenomenon during healing of a bone defect in the rat. Calcif Tissue Int 1998; 63:160–166.

Indexed at, Google Scholar, Cross Ref

15. Kumar S, Parashar P, Singla V, et al. Wilckodontics: A multidisciplinary treatment approach in dentistry. Int J Res  Develop  Pharm Life Sci 2015; 4:1801-1807.

Google Scholar

16. Shih MS, Norrdin RW. Regional acceleration of remodeling during healing of bone defects in beagles of various ages. Bone 1985; 6:377–379.

Indexed at, Google Scholar, Cross Ref

17. Patil C, Jadhav A, Rajanikanth K, et al. Piezosurgery vs. bur in impacted mandibular third molar surgery: Evaluation of postoperative sequelae. J Oral Biol Craniofacial Res 2019; 9:259–262.

Indexed at, Google Scholar, Cross Ref

18. Dibart S, Sebaoun JD, Surmenian J. Piezocision: A minimally invasive, periodontally accelerated orthodontic tooth movement procedure. Compend Contin Educ Dent Jamesburg NJ 2009; 30:342–344.

Indexed at, Google Scholar

19. Khandait CH, Pakhare V, Shrivastav S, et al. Rapidifying the orthodontic treatment using peizosurgery: A case report. Med 2017.

Google Scholar

20. Vercellotti T, Podesta A. Orthodontic microsurgery: A new surgically guided technique for dental movement. Int J Periodontics Restorative Dent 2007; 27.

Indexed at, Google Scholar

21. Kim SJ, Park YG, Kang SG. Effects of corticision on paradental remodeling in orthodontic tooth movement. Angle Orthod 2009; 79:284–291.

Indexed at, Google Scholar, Cross Ref

22. Park YG, Kang SG, Kim SJ. Accelerated tooth movement by corticision as an osseous orthodontic paradigm. Kinki Tokai Kyosei Shika Gakkai Gakujyutsu Taikai Sokai 2006; 48:6–15.

Google Scholar

23. Dibart S, Surmenian J, David Sebaoun J, et al. Rapid treatment of Class II malocclusion with piezocision: Two case reports. Int J Periodontics Restorative Dent 2010; 30:487.

Indexed at, Google Scholar

24. Farid KA, Mostafa YA, Kaddah MA, et al. Corticotomy-facilitated orthodontics using piezosurgery versus rotary instruments: An experimental study. J Int Acad Periodontol 2014; 16:103–108.

Indexed at, Google Scholar

25. Aksakalli S, Calik B, Kara B, et al. Accelerated tooth movement with piezocision and its periodontal-transversal effects in patients with Class II malocclusion. Angle Orthod 2016; 86:59–65.

Indexed at, Google Scholar, Cross Ref

26. https://52.5.142.101/bitstream/handle/10946/4927/Informe%20con%20anexos.pdf?sequence=3&isAllowed=y
27. Rathod N, Deshmukh SV, Agarkar S, et al. Comparative evaluation of speed of orthodontic tooth movement with or without piezocision technique: An In vivo study. J Int Clin Dent Res Organ 2019; 11:90.

Indexed at, Google Scholar

28. Seifi M, Younessian F, Ameli N. The innovated laser assisted flapless corticotomy to enhance orthodontic tooth movement. J Laser Med Sci 2012; 3:20-25.

Indexed at, Google Scholar

29. Ambashikar VR, Kangane SK, Ambekar SA, et al. Fast track orthodontics: A review on methods of accelerating orthodontic treatment. Int J Orthod Rehabil 2021; 12:72.

Indexed at, Google Scholar

30. Parihar AS, Narang S, Singh N, et al. Periodontally accelerated osteogenic orthodontics: A perio-ortho ambidextrous perspective. J Fam Med Prim Care 2020; 9:1752.

Indexed at, Google Scholar, Cross Ref